a nurse manager is preparing to review medication documentation with a group of newly licensed nurses which of the following statements should the nur a nurse manager is preparing to review medication documentation with a group of newly licensed nurses which of the following statements should the nur
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1. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

Correct answer: C

Rationale: The correct statement that the nurse manager should include in the teaching session is to use the abbreviation SC when indicating a subcutaneous injection. This is important for accurate and standardized medication documentation. Choice A is incorrect because using the complete name of medications is not always necessary and may lead to errors. Choice B is incorrect as spaces between dose and unit of measure are required for clarity and to avoid misinterpretation. Choice D is incorrect because the standard abbreviation for units should be used instead of the letter U to prevent confusion.

2. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

3. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

4. The client on furosemide (Lasix) is at risk for which electrolyte imbalance?

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance is a significant risk associated with diuretic use. Choices A, C, and D are incorrect. Hyperkalemia (choice A) is not typically associated with furosemide use. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels, not potassium levels affected by furosemide.

5. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.

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